Delays in referral and diagnosis for chronic hematologic malignancies: A literature review

Diagnostic Interval in Extranodal Non-Hodgkin Head and Neck Lymphomas

The aim of this study is to measure the diagnostic interval (DI) of primary extranodal non-Hodgkin lymphomas (PE-NHL) affecting the head and neck and to discover any associated factors. With this aim, we performed a retrospective observational study in northwestern Spain on patients diagnosed between 1 January 2005 and 1 January 2016. A search was made across the electronic health records of the public health system of this region (SERGAS). DI was used as the dependent variable, and different clinicopathological data of the corresponding patients and tumors were analyzed as exposure variables. PE-NHLs were mostly located in Waldeyer’s ring, and they presented a B phenotype and had a median DI of 65 days. Shorter diagnostic intervals were observed in (1) PE-NHL patients who had comorbidities (p = 0.02), (2) PE-NHL that caused symptoms of dysphagia (p = 0.04), (3) tumors with the highest proliferative activity (Ki67 > 80%) (p = 0.04), and (4) tumors diagnosed in the advanced stages of the disease (p = 0.004). Univariate analysis revealed a significant association between dysphagia and a shorter DI. We conclude that raising awareness about these neoplasms and warning about the presenting symptoms can contribute to earlier diagnoses of these tumors and to better outcomes.

Development of an algorithm for the identification of leukemic hematolymphoid neoplasms in Primary Care patients

BACKGROUND

Diagnosis of hematolymphoid neoplasm (HLN) requires different technologies which are performed on a patient basis instead of per protocol. We hypothesize that integration of hematimetric and cytological analysis along with multiparametric flow cytometry (MFC) provides a framework to evaluate peripheral blood (PB) samples from Primary Care.

METHODS

Samples from patients with persistent (>3 months) lymphocytosis (>5 × 109/L) and/or monocytosis (>109/L) or the presence of atypical and/or blast cells upon the smear review were analyzed by MFC concurrent to cytological analysis. MFC studies were carried out following standardized procedures.

RESULTS

In a 3-year period, smear review and MFC were performed simultaneously in 350 samples, demonstrating HLN in 194 cases (55.4%). In 156 cases, reactive cell populations were found. The combination of age, absolute lymphocyte count (ALC), hemoglobin and platelets provided the best correlation with MFC for the presence of a chronic lymphoproliferative disorder (CLPD) in lymphocytosis [area under the curve (AUC) 0.891, p < 0.05]. A model evaluating the probability of CLPD has been proposed and validated in an independent cohort.

CONCLUSIONS

A strategy to perform MFC studies following standardized procedures has proven to be useful to evaluate samples from patients in Primary Care centers for HLN diagnosis or reactive conditions, providing a sensitive and rapid clinical orientation and avoiding unnecessary consultations in routine clinical practice. The probability for the presence of CLPD in PB can be calculated and help guide decision-making regarding further testing.

Understanding quality and equity: patient experiences with care in older adults diagnosed with hematologic malignancies

BACKGROUND

Oncology settings increasingly use patient experience data to evaluate clinical performance. Given that older patients with hematologic malignancies are a high-risk population, this study examined factors associated with patient-reported health care experiences during the first year of their cancer diagnosis.

METHODS

Cross-sectional study using the 2000-2015 SEER-CAHPS® data to examine patient experiences of Medicare enrollees with a primary diagnosis of leukemia or lymphoma. The primary outcomes were three CAHPS assessments: overall care, personal doctor, and health plan overall. We estimated case-mix adjusted and fully adjusted associations between factors (i.e., clinical and sociodemographic) and the CAHPS outcomes using bivariate statistical tests and multiple linear regression.

RESULTS

The final sample included 1,151 patients, with 431 diagnosed with leukemia and 720 diagnosed with lymphoma (median time from diagnosis to survey 6 months). Patients who completed the survey further apart from the diagnosis date reported significantly higher adjusted ratings of care overall (β .39, p = .008) than those closer to diagnosis. American Indian/Alaska Native, Asian, and Pacific Islander patients had lower adjusted ratings of care overall (β - .73, p = .003) than Non-Hispanic white patients. Multimorbidity was significantly associated with higher adjusted personal doctor ratings (β .26, p = .003).

CONCLUSIONS

Unfavorable patient experiences among older adults diagnosed with hematologic malignancies warrant targeted efforts to measure and improve care quality. Future measurement of experiences of cancer care soon after diagnosis, coupled with careful sampling of high-priority populations, will inform oncology leaders and clinicians on strategies to improve care for high-risk, high-cost populations.

Time from Symptom Onset to Diagnosis and Treatment among Haematological Malignancies: Influencing Factors and Associated Negative Outcomes

Background and objectives: Diagnostic delay causes unfavorable outcomes among cancer patients. It has been widely analyzed in solid tumors. However, data regarding hematological malignancies diagnostic delay are scarce. We aimed to evaluate diagnostic intervals, their influencing factors, and the negative effect on clinical outcomes among multiple myeloma and lymphoma patients. Materials and methods: One hundred patients diagnosed with multiple myeloma (n = 53) or lymphoma (n = 47) (ICD codes-C90, C81-C84) were asked to participate during their scheduled hematology consultations. Interval durations and the majority of influencing factors were assessed based on a face-to-face questionnaire. Data of disease characteristics were collected from medical records. Results: The median interval from symptom onset to registration for medical consultation was 30 (0-730) days, from registration to consultation 2 (0-30) days, from first consultation to diagnosis 73 (6-1779) days, and from diagnosis to treatment 5 (0-97) days. Overall time to diagnosis median was 151 (23-1800) days. Factors significantly prolonging diagnostic intervals in multivariate linear regression were living in big cities (p = 0.008), anxiety and depression (p = 0.002), self-medication (p = 0.019), and more specialists seen before diagnosis (p = 0.022). Longer diagnostic intervals resulted in higher incidences of multiple myeloma complications (p = 0.024) and more advanced Durie-Salmon stage (p = 0.049), but not ISS stage and Ann-Arbor staging systems for lymphomas. Conclusion: Median overall diagnostic delay was nearly 5 months, indicating that there is room for improvement. The most important factors causing delays were living in big cities, anxiety and depression, self-medication, and more specialists seen before diagnosis. Diagnostic delay may have a negative influence on clinical outcomes for multiple myeloma patients.

The impact of structural factors on diagnostic delay in diffuse large B-cell lymphoma

BACKGROUND

Reducing diagnostic delays in cancer has been a major interest worldwide; however, the literature on diagnostic delays in lymphoma remains scarce. Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin's lymphoma. We aimed to determine whether certain structural factors predicted diagnostic delays in DLBCL and whether diagnostic delays impacted overall survival (OS).

METHODS

Data were extracted via a retrospective cohort design from a single academic tertiary care referral center. A total of 104 patients were included. Time from first symptoms to diagnosis of <3 months was defined as "early diagnosis" and ≥3 months as "delayed diagnosis". Analysis was performed with student's t-test, chi-square testing, binomial logistic regression, and Kaplan-Meier log-rank testing.

RESULTS

"Delayed diagnosis" was more likely with lower stage, lower international prognostic index (IPI), and further distance from referral center (OR 0.66, CI 0.46-0.95; OR 0.69, CI 0.51-0.94; OR 1.008, CI 1.001-1.015). Patients of "other" ethnicity and without medical insurance were more likely to have significant diagnostic delays and worse overall survival (P = 0.002 and P = 0.007, respectively). Diagnostic delays of ≥3 months did not predict worse OS. However, delays of >6 months did predict worse OS.

CONCLUSION

Our data suggest that excessive diagnostic delays of more than 6 months, ethnic minority status, and uninsured status in DLBCL may lead to worse outcomes. Efforts should be undertaken to reduce excessive diagnostic delays. More investigation needs to be done on the impacts of diagnostic delays in both DLBCL and other aggressive lymphomas.

Presentation and survival in patients with hematologic malignancies in Jos, Nigeria: A retrospective cohort analysis

Background

Haematologic malignancies cause significant morbidity and mortality and are not uncommon in resource-limited-low income countries. However, the types, pattern of presentation and treatment outcomes vary across regions. We assessed the presentation and overall survival over an 11-year period in adult patients presenting with haematologic cancers in Jos, North Central Nigeria.

Materials and Methods

This retrospective outcome study evaluated patients who presented with haematologic malignancies between 2005-2015 at the Jos University Teaching Hospital (JUTH), Jos. Variables of interest were abstracted through chart reviews. Descriptive statistics were used to evaluate baseline and follow-up parameters. Overall survival (OS) was assessed using Kaplan-Meier method.

Results

Sixty patients, contributing 25,994 person-days of follow-up were evaluated. The mean age was 43+17 years and 61.7% were males. Thirty-one patients (51.7%) presented with leukemia, 45.0% with lymphoma, and 3.3% with multiple myeloma. Forty-two (70.0%) presented with advanced disease, 5 (5.2%) were HIV positive and 4 (6.7%) had died at the end of follow-up. OS was 84.3% (95% CI: 58.1-94.7). Survival differed by disease group (p=0.01) and having fever at presentation (p=0.02).

Conclusion

We found long-term OS to be impacted by disease type and status of fever at presentation. Disease-specific Strategies to improve early diagnosis and therapies are needed to ensure optimal outcomes in Nigerian patients.

Decision-making and referral processes for patients with motor neurone disease: a qualitative study of GP experiences and evaluation of a new decision-support tool

BACKGROUND

The diagnosis of motor neurone disease (MND) is known to be challenging and there may be delay in patients receiving a correct diagnosis. This study investigated the referral process for patients who had been diagnosed with MND, and whether a newly-developed tool (The Red Flags checklist) might help General Practitioners (GPs) in making referral decisions.

METHODS

We carried out interviews with GPs who had recently referred a patient diagnosed with MND, and interviews/surveys with GPs who had not recently referred a patient with suspected MND. We collected data before the Red Flags checklist was introduced; and again one year later. We analysed the data to identify key recurring themes.

RESULTS

Forty two GPs took part in the study. The presence of fasciculation was the clinical feature that most commonly led to consideration of a potential MND diagnosis. GPs perceived that their role was to make onward referrals rather than attempting to make a diagnosis, and delays in correct diagnosis tended to occur at the specialist level. A quarter of participants had some awareness of the newly-developed tool; most considered it useful, if incorporated into existing systems.

CONCLUSIONS

While fasciculation is the most common symptom associated with MND, other bulbar, limb or respiratory features, together with progression should be considered. There is a need for further research into how decision-support tools should be designed and provided, in order to best assist GPs with referral decisions. There is also a need for further work at the level of secondary care, in order that referrals made are re-directed appropriately.

Predictors of delay in diagnosis and treatment in diffuse large B-cell lymphoma and impact on survival

There is a paucity of data on the impact of diagnostic and treatment delays on outcomes in haematological malignancies, particularly in patients with diffuse large B-cell lymphoma (DLBCL). Our database of patients treated for DLBCL between 2002 and 2010 was interrogated. Univariate and multivariate analyses were performed to determine the relationship between sociodemographic or disease-specific variables and delays. Cox Regression analysis was used to discern the impact of delays on survival. Patients (n = 278) waited a median of 4 weeks before seeking medical attention. It took a median of 8 weeks for a non-haematology physician to diagnose DLBCL and refer to a haematologist. A median of 3 weeks elapsed between specialist consultation and chemotherapy initiation. In multivariate logistic regression analysis, bone marrow involvement [odds ratio (OR) = 0·41, P = 0·018], Charlson comorbidity index (OR = 1·42, P = 0·017) and urgent inpatient chemotherapy (OR = 0·40, P = 0·012) were associated with diagnostic delays >6 weeks. Lack of pathological diagnosis at the time of haematology referral was the only factor that independently predicted for treatment delays >4 weeks (OR = 8·25, P < 0·01). Diagnostic or treatment delays did not impact survival or progression-free survival. In conclusion, selected disease and patient-related factors are associated with delays in management of DLBCL, but do not impact outcomes.

Evaluation of unexplained peripheral lymphadenopathy and suspected malignancy using a distinct quick diagnostic delivery model: prospective study of 372 patients

Although rapid diagnostic testing is essential in suspicious peripheral lymphadenopathy, delays in accessing them can be considerable. We investigated the usefulness of an internist-led outpatient quick diagnosis unit (QDU) in assessing patients with unexplained peripheral lymphadenopathy, focusing on the characteristics, diagnostic, and treatment waiting times of those with malignancy. Patients aged ≥ 18 years, consecutively referred from 12 primary health care centers (PHCs) or the emergency department (ED) for unexplained peripheral lymphadenopathy, were prospectively evaluated during 7 years. Diagnostic investigations were done using a predefined study protocol. Three experienced cytopathologists performed a fine-needle aspiration cytology (FNAC) systematic approach of clinically suspicious lymphadenopathy with cytomorphology and immunophenotyping analyses. We evaluated 372 patients with a mean age (SD) of 45.3 (13.8) years; 56% were women. Malignancy was diagnosed in 120 (32%) patients, including 81 lymphomas and 39 metastatic tumors. Metastatic lymphadenopathy was diagnosed by FNAC in all 39 patients and the primary tumor site was identified in 82% of them when cytomorphology and immunocytochemistry were combined. A correct diagnosis of lymphoma was reached by FNAC in 73% of patients. When accepting "suspicious of" as correct diagnosis, the FNAC diagnosis rate of lymphoma increased to 94%. Among patients with malignancy, FNAC yielded 1.3% of false negatives and no false positives. All patients with an FNAC report of correct or suspicious lymphoma underwent a surgical biopsy, as it is a mandatory requirement of the hematology department. Mean times from first QDU visit to FNAC diagnosis of malignancy were 5.4 days in metastatic lymphadenopathy and 7.5 days in lymphoma. Mean times from receiving the initial referral report to first treatment were 29.2 days in metastatic lymphadenopathy and 40 days in lymphoma. In conclusion, a distinct internal medicine QDU allows an expeditious, agile, and prearranged system to diagnose malignant peripheral lymphadenopathy. Because of the close collaboration with the cytopathology unit and the FNAC methodical approach, diagnostic and treatment waiting times of patients with malignancy fulfilled national and international time frame standards. This particular diagnostic delivery unit could help overcome the difficulties facing PHC, ED, and other physicians when trying to provide rapid access to investigations to patients with troublesome lymphadenopathy.

Diagnostic testing managed by hematopathology specialty and other laboratories: costs and patient diagnostic outcomes

BACKGROUND

Successful management of patients with hematologic malignancies depends upon accurate and timely diagnosis, which frequently requires integration and interpretation of multiple tests. Our retrospective analysis compared diagnostic uncertainty, resource utilization, and costs for patients with diagnostic bone marrow (BM) tests managed by commercial laboratories.

METHODS

Patients with BM biopsies and suspected hematologic cancer/condition were identified from claims (2005-2011) within a large US health plan (coverage ≥6 pre- and ≥3-months post-biopsy). Cohorts defined by laboratories performing BM morphologic assessment/directing testing sequence: Genoptix (GX, specialty hematology-testing laboratory), large commercial laboratories (LL), other laboratories (OL). One-year post-biopsy changes in diagnosis or treatments, tests performed, and diagnostic/treatment medical costs (measured as per-patient-per-month [PPPM]) were examined.

RESULTS

The study population included 1,387 GX, 4,162 LL, and 19,115 OL patients with suspected hematologic malignancy/disease and BM morphology assessment. GX had lower diagnostic uncertainty measured between 2 time periods by diagnostic stability (no conditions the same; 6.16% GX, 8.04% LL, 9.73% OL; p < 0.001) and changes (≥1 condition different; 7.88% GX, 11.19% LL, and 14.08% OL; p < 0.001), fewer repeat BM biopsies, and fewer chemotherapy changes (30-days and 60-days post-initiation). One-year PPPM costs adjusted for patient characteristics differences were $8,202 GX, $7,711 LL, and $10,302 OL (p < 0.05); adjusted PPPM costs (excluding testing period) were $6,019 GX, $6,649 LL, and $7,801 OL (p < 0.05).

CONCLUSIONS

Our data suggests that a hematopathology specialty laboratory may result in earlier final diagnosis, fewer subsequent diagnosis changes, reduced need for follow-on testing requiring repeat biopsy procedures, and may result in lower downstream healthcare costs. Further evaluations using medical chart abstractions or registries will be valuable.

Underestimation of myelodysplastic syndrome incidence by cancer registries: Results from a population-based data linkage study

BACKGROUND

Myelodysplastic syndromes (MDS) appear to be underreported to cancer registries, with important implications for cancer and transfusion support service planning and delivery. Two population-based databases were linked to estimate MDS incidence more accurately.

METHODS

Data from the statewide Victorian Cancer Registry (VCR) and Victorian Admitted Episode Dataset (VAED, capturing all inpatient admissions), in Australia, were linked. Incidence rates were calculated based on VCR reported cases and using additional MDS cases identified in VAED. Differences between reported and nonreported cases were assessed. A multivariate capture-recapture method was used to estimate missed cases.

RESULTS

Between 2003 and 2010, 2692 cases were reported to VCR and an additional 1562 cases were identified in VAED. Annual incidence rate for those aged 65 years and older based on VCR was 44 per 100,000 (95% confidence interval [CI] = 43-45 per 100,000) and 68 per 100,000 (95% CI = 67-70 per 100,000) using both data sets. Cases not reported to VCR were more likely to have had previous malignancies recorded in VAED (23% versus 19%, P = .003) and to require red cell transfusion (59% versus 54%, P = .003). Using the multivariate model, an estimated 1292 cases were missed by both data sources: the re-estimate was 5546 (95% CI = 5438-5655) MDS cases, with an annual incidence in those aged 65 or older of 103 per 100,000 (95% CI = 100-106).

CONCLUSIONS

This study reports a higher incidence of MDS using 2 data sources from a large and well-defined population than reported using cancer registry notifications alone.

Neurologic aspects of lymphoma and leukemias

The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This review's focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.

Referrals for suspected hematologic malignancy: a survey of primary care physicians

Little is known about referrals from primary care providers (PCPs) for suspected hematologic malignancies, including their clinical triggers and frequency. A random sample of 190 Massachusetts PCPs were presented with a vignette concerning a patient with a new finding of moderate anemia, asked how they would respond, and then asked what they would do if the patient returned with persistent anemia plus one additional sign or symptom. We also asked about referral behaviors for suspected hematologic malignancies during the prior year. A total of 134 (70.5%) PCPs responded. At first anemia presentation,only 3.8% reported referring to hematology. The development of a second sign or symptom yielded higher referral rates: pancytopenia 588.7%, leukopenia 5 63.9%, thrombocytopenia 5 63.9%, lymphadenopathy 5 42.9%, leukocytosis 5 37.6%, night sweats 5 25.6%, and weight loss 5 23.3%. The median yearly number (interquartile range) of patients PCPs reported suspecting of having hematologic malignancy was 5 (3, 10), and the median formally referred was 5 (3, 10). We conclude that anemia plus signs and symptoms suggestive of myelodysplasia or leukemia (compared with those suggestive of lymphoma) are more likely to prompt hematology referral. In addition, given their rarity,the numbe

Neurologic aspects of lymphoma and leukemias

The leukemias and lymphomas represent a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized almost since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders has evolved along with our knowledge of the malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize the heralding features. This review focuses on the relevant clinical neurologic features and diagnostic studies to identify leukemias and lymphomas affecting the nervous system.

Timeliness and quality of diagnostic care for medicare recipients with chronic lymphocytic leukemia

BACKGROUND

Little is known about the patterns of care relating to the diagnosis of chronic lymphocytic leukemia (CLL), including the use of modern diagnostic techniques such as flow cytometry.

METHODS

The authors used the SEER-Medicare database to identify subjects diagnosed with CLL from 1992 to 2002 and defined diagnostic delay as present when the number of days between the first claim for a CLL-associated sign or symptom and SEER diagnosis date met or exceeded the median for the sample. The authors then used logistic regression to estimate the likelihood of delay and Cox regression to examine survival.

RESULTS

For the 5086 patients analyzed, the median time between sign or symptom and CLL diagnosis was 63 days (interquartile range [IQR] = 0-251). Predictors of delay included age ≥75 (OR 1.45 [1.27-1.65]), female gender (OR 1.22 [1.07-1.39]), urban residence (OR 1.46 [1.19 to 1.79]), ≥1 comorbidities (OR 2.83 [2.45-3.28]) and care in a teaching hospital (OR 1.20 [1.05-1.38]). Delayed diagnosis was not associated with survival (HR 1.11 [0.99-1.25]), but receipt of flow cytometry within thirty days before or after diagnosis was (HR 0.84 [0.76-0.91]).

CONCLUSIONS

Sociodemographic characteristics affect diagnostic delay for CLL, although delay does not seem to impact mortality. In contrast, receipt of flow cytometry near the time of diagnosis is associated with improved survival.

Outcomes for lymphoid malignancies in the Nurses' Health Study (NHS) as compared to the Surveillance, Epidemiology and End Results (SEER) Program

Vital statistics for the lymphoid malignancies obtained from the Surveillance, Epidemiology and End Results (SEER) Program have seldom been directly compared to data from alternative national databases. While SEER is recognized as the standard, some lymphoid malignancies-especially the chronic ones--may be underreported. We compared the incidence, all-cause and cause-specific mortality for Hodgkin's lymphoma (HL), non-Hodgkin's lymphoma (NHL), multiple myeloma (MM) and chronic lymphocytic leukaemia (CLL) in SEER to that in the Nurses' Health Study (NHS), a national cohort study of 121,700 female registered nurses, matching for age and race. In over 2.5 million person-years, the incidence of HL was the same as in SEER (SIR=1.01 [0.75, 1.26]), while the incidence of NHL, CLL and MM were slightly higher. All-cause mortality was lower for the lymphoid malignancies except for MM, which was the same; there were no differences in cause-specific mortality, except for MM (HR=1.26 [1.07, 1.48]). Our analysis suggests that, at least among white women, SEER is a reliable data source with respect to lymphoid malignancies.

Diagnostic delay and complications for older adults with multiple myeloma

Increased attention to timely diagnosis motivated us to study 5483 patients diagnosed with multiple myeloma using Medicare claims linked to tumor registries in the Surveillance, Epidemiology and End Results programme. We calculated the time between initial visits for anemia or back pain and for myeloma diagnosis, and used logistic regression to predict the likelihood of diagnostic delay, and also the likelihood of renal or skeletal complications. The median time between sign or symptom and myeloma diagnosis was 99 days. Patients with anemia, back pain and comorbidities were more likely to experience diagnostic delay (OR 1.6, 95% CI 1.3-2.0). Diagnosis while hospitalised (OR 2.5, 95% CI 2.2-2.9) and chemotherapy treatment within 6 months of diagnosis (OR 1.4, 95% CI 1.2-1.6) significantly predicted complications; diagnostic delay did not (OR 0.9, 95% CI 0.8-1.1). Our data suggest that complications are more strongly associated with health status and myeloma severity than with diagnostic delays.